4 pts
2 pts
0 pts
Assess and document as needed including UBW and/or BMI
Assess and document as needed *If your note does not have a need for estimated calories/pro do not include these points in total points possible.
Assess and document pertinent labs as appropriate for patient and/or diagnosis
Assess and document medications as appropriate for patient and/or diagnosis
Assess and document as appropriate for patient and/or dx
Document well defined plan outlining specific goals of care and interventions